Otu et al. Human Resources for Health (2016) 14:5 DOI 10.1186/s12960-016-0100-4
RESEARCH
Open Access
Using a mHealth tutorial application to change knowledge and attitude of frontline health workers to Ebola virus disease in Nigeria: a before-and-after study Akaninyene Otu1*, Bassey Ebenso2, Okey Okuzu3,4 and Egbe Osifo-Dawodu5
Abstract Background: The Ebola epidemic exposed the weak state of health systems in West Africa and their devastating effect on frontline health workers and the health of populations. Fortunately, recent reviews of mobile technology demonstrate that mHealth innovations can help alleviate some health system constraints such as balancing multiple priorities, lack of appropriate tools to provide services and collect data, and limited access to training in health fields such as mother and child health, HIV/AIDS and sexual and reproductive health. However, there is little empirical evidence of mHealth improving health system functions during the Ebola epidemic in West Africa. Methods: We conducted quantitative cross-sectional surveys in 14 health facilities in Ondo State, Nigeria, to assess the effect of using a tablet computer tutorial application for changing the knowledge and attitude of health workers regarding Ebola virus disease. Results: Of 203 participants who completed pre- and post-intervention surveys, 185 people (or 91%) were female, 94 participants (or 46.3%) were community health officers, 26 people (13 %) were nurses/midwives, 8 people (or 4%) were laboratory scientists and 75 people (37%) belonged to a group called others. Regarding knowledge of Ebola: 178 participants (or 87.7%) had foreknowledge of Ebola before the study. Further analysis showed an 11% improvement in average knowledge levels between pre- and post-intervention scores with statistically significant differences (P < 0.05) recorded for questions concerning the transmission of the Ebola virus among humans, common symptoms of Ebola fever and whether Ebola fever was preventable. Additionally, there was reinforcement of positive attitudes of avoiding the following: contact with Ebola patients, eating bush meat and risky burial practices as indicated by increases between pre- and post-intervention scores from 83 to 92%, 57 to 64% and 67 to 79%, respectively. Moreover, more participants (from 95 to 97%) reported a willingness to practice frequent hand washing and disinfecting surfaces and equipment following the intervention, and more health workers were willing (from 94 to 97%) to use personal protective equipment to prevent the transmission of Ebola. Conclusions: The modest improvements in knowledge and reported attitudinal change toward Ebola virus disease suggests mHealth tutorial applications could hold promise for training health workers and building resilient health systems to respond to epidemics in West Africa. Keywords: Ebola virus disease, Improving knowledge and attitude, mHealth, Frontline health workers, Nigeria
* Correspondence:
[email protected] 1 Department of Internal Medicine, College of Medical Sciences, University of Calabar, P.M.B. 11115, Calabar, Cross River State, Nigeria Full list of author information is available at the end of the article © 2016 Otu et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Otu et al. Human Resources for Health (2016) 14:5
Background The Ebola virus disease (EVD) outbreak in West Africa commenced in a remote area of southern Guinea in December 2013 while the first cases were reported in March 2014. Unlike previous outbreaks in East and Equatorial Africa [1] that were brought under control fairly swiftly, the West African outbreak is considered the worst in history due to an almost unimpeded spread from Guinea to Sierra Leone, Senegal, Liberia, Mali and Nigeria [2, 3]. The growing concern that followed its spread to other countries and the cumulative number of deaths led to the declaration of EVD as a Public Health Emergency of International Concern by the World Health Organization (WHO) in August 2014 [2]. EVD has a case fatality rate of 60–90%, and there is still no available drug or vaccine [3] for the disease [4]. The initial spread of EVD in West Africa was fuelled by socio-cultural factors and a collective failure to ensure availability of adequate health staff, basic healthcare resources and systems in the most affected countries [5, 6]. Subsequent patterns of spread revealed that health services in affected countries were overstretched by the epidemic [7] and that frontline health workers (FHWs) were at increased risk of contracting EVD by coming in contact with body fluids of infected patients. Many health workers who dealt with the outbreak were neither provided with protective clothing nor equipment to reduce their risk of infection when caring for patients and/or the deceased. In the USA and Spain where personal protective equipment was in abundant supply, FHWs were put at risk by inadequate training on how to safely provide medical care to persons with EVD. This situation led to an unprecedented number of infections and deaths among FHWs, thus depleting a vital asset during the control of the outbreak. By 12 April 2015, about 868 (or 3.4%) cases of Ebola reported globally were among health workers, 503 (or 2%) of who died from the disease [2, 6]. Understandably, the moral, physical and psychological consequences of the epidemic dampened the enthusiasm of FHWs [8] to provide essential services in affected countries. The hesitancy of FHWs to put themselves in harm’s way placed an even greater strain on fragile health systems. To counteract this situation, the presidents of affected countries and the Director-General of the WHO launched a joint $100 million emergency response to control the epidemic, including through providing adequate protective clothing, training and support for anyone who was in contact with Ebola patients [7]. Integral to the emergency plan were collaborations between national governments and mobile network providers to harness the high penetration of mobile phone subscription in Guinea (63/100 people), Liberia (60/100 people) and Sierra Leone (44/100 people) to provide low-cost, high-impact mobile health (mHealth) solutions [9] for mapping outbreaks,
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providing education interventions to support behaviour change [10] and providing reference and training materials that FHWs can download onto their phones [8, 11]. In many ways, the successful utilization of advanced wireless technologies to fight the Ebola outbreak in Nigeria drove the increased focus on mobile phones elsewhere in the region. These partnerships aimed to tap into phenomenal growths in information and communication technology (ICT) in low- and middle-income countries (LMICs), to improve health and healthcare services in countries affected by Ebola. The use of mHealth technology refers to the incorporation of wireless devices such as mobile phones, tablets, personal diagnostic assistants (PDAs), patient-monitoring devices and other wireless devices into medical and public health practice to improve health or ensure healthcare [9, 11–13]. Recent reviews show the explosive innovation in technology has inspired a proliferation of mHealth pilot initiatives, many of which have demonstrated that mHealth can alleviate specific health system barriers such as balancing multiple priorities, lack of appropriate tools to provide services and collect data, and limited access to training and supervision [14, 15]. Despite the utility of mHealth for strengthening health systems in a range of health fields including mother and child health (MCH), management of diabetes and HIV treatment [11], there is little empirical evidence of the effectiveness of mHealth in improving health system functions during the West African Ebola epidemic. This paper therefore aimed to assess the effect of using a tablet computer application to deliver an education intervention to change frontline health workers’ EVD-related knowledge and attitude in Nigeria. We sought to answer the following questions: (a) are tablet computer applications effective for streaming EVD-related tutorial to FHWs, in the context of an epidemic, and (b) what is the effect of the education intervention (tutorial) on FHWs’ knowledge about and attitude toward EVD? The hypotheses were that (i) EVD-related information can be delivered at a distance from tablet computers to FHWs in the context of an epidemic and (ii) tablet-delivered education intervention could positively change FHWs’ biomedical knowledge of EVD. Conceptual clarification of terms mHealth interventions
As already mentioned in the preceding paragraphs, mHealth uses wireless devices to support medical and public health practice to improve health or healthcare [16]. mHealth interventions may include, e.g. using mobile short text messages (SMS) to stimulate the uptake of service and patient adherence to medication as well as to educate caregivers and ensure provider compliance with clinical protocols [17].
Otu et al. Human Resources for Health (2016) 14:5
Education interventions
The aim is to provide intervention participants (patients, general public or health providers) with disease-specific information [18] to increase awareness and knowledge of symptoms, causes and consequences of diseases in order to improve disease control and promote healthcareseeking behaviour in populations [19, 20]. Some scholars, however, claim that education interventions can also change beliefs and attitudes toward disease conditions [21]. Unlike mHealth interventions which primarily use mobile/wireless devices to support improvements in health or healthcare, education interventions, on the other hand, can be delivered through a range of strategies including the following: traditional face-to-face lectures, videos and films, internet-based approaches and mobile phone and tablet technology to enable training of participants [22]. This paper reports an education intervention that used tablet computers as a medium to facilitate the training of frontline health workers. The intervention was a component of the ‘Front Line health worker Education and disease Management (FLEM) project’, developed by Instrat and Anadach and implemented on the Vecna Cares CliniPAK system under a Qualcomm® Wireless Reach™ grant. The FLEM project was implemented in collaboration with the Ondo State Government in Nigeria with the objective of improving emergency preparedness of the health system to contain the Ebola outbreak.
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the urban compared to rural areas [25]. Regarding health indicators, Ondo State has a maternal mortality rate of 371/100 000 live births and an infant mortality rate of 68/1000 live births, considered by the World Bank in June 2009 as the worst health indices in South West Nigeria [28]. This catalysed the ministry of health (MOH) to provide health services free of cost to pregnant women and children aged
